Delayed Surgical Treatment of a CE1 Lung Cyst Resulting in Pericystectomy of CE4 Cyst.

Lung is the second most common locationof cystic echinococcosis (CE), after the liver. Diagnosis of lung CE is often incidental, and clinical manifestations depend on the location and size of the cyst, the most common being chest pain, shortness of breath, expectoration of fragments of endocyst, and haemoptysis. Surgery is the primary treatment, with a minor role for medical therapy. Delayed diagnosis and treatment may have important consequences. We present a case of lung CE in whichsurgical treatment was delayed due to the first wave of COVID-19. Since surgery could not be performed immediately, the patient was kept on albendazole and the cyst stage moved from CE1 to CE3a, to CE4, eventually requiring a more aggressive pericystectomy instead of the commonly performed endocystectomy. The clinical and imaging characteristics of a rare CE4 cyst of the lung are reported.

Circumferential esophageal leiomyoma: Management by combined robotic surgery and intraoperative endoscopy.

Leiomyoma is the most common benign tumor of the esophagus. Open thoracotomy, the traditional approach adopted for the enucleation of the esophageal leiomyoma, over the years, has been gradually replaced by video-assisted thoracoscopic surgery. However, this minimally invasive approach has limitations, such as two-dimensional vision and reduced range of motion, which have recently been overcome by technical advantages of robot-assisted surgery. In the surgical management of circumferential esophageal leiomyoma, a combined use of robotic surgery and intraoperative endoscopy may be helpful to facilitate tumor enucleation and to prevent esophageal mucosal injury during the surgical procedure.

Comments on "The surgical approach of late-onset tracheoesophageal fistula in a tracheostomized COVID-19 patient".

Dear Editor, we have read with interest the case reported by Rotolo et al.  (published in February 2023 as Early Access) concerning the surgical management of tracheoesophageal fistula (TEF) in a COVID-19 patient treated with prolonged mechanical ventilation for severe respiratory failure.

Persistent alveolar air leak following pulmonary lobectomy: an old problem in a modern era.

Persistent alveolar air leak (PAAL) after major lung resection remains a common complication in thoracic surgery. The aim of this study was to identify a subset of patients with high risk of developing PAAL after pulmonary lobectomy. Another objective was to evaluate the influence of PAAL on postoperative complications and length of hospital stay. A retrospective analysis on 895 patients undergoing pulmonary lobectomy from January 2014 to December 2019 was performed. PAAL was defined as air leak lasting more than 5 days after lung surgery. Univariate analyses and logistic regressions were performed to identify the predictors of PAAL. A backward selection algorithm was used to identify the optimal set of predictors. The incidence of PAAL was 8.2% (74/895). Male gender (p=0.017), BMI (p<0.001), transient ischemic attack (p=0.031), FEV1 (p=0.018), lobectomy combined with adjacent subsegmentectomy (p=0.018), partial and extended pleural adhesions (p=0.033 and p=0.038, respectively) were identified as independent risk factors for PAAL through logistic regression. A weak positive correlation was found between video-assisted thoracic surgery (VATS) and PAAL following pulmonary lobectomy (p=0.100). PAAL was found to be associated with higher risk of postoperative morbidity (p=0.002) and with longer hospital stay (p<0.001). Both preoperative and intraoperative risk factors may be responsible for PAAL after pulmonary lobectomy. VATS does not appear to prevent this postoperative complication. An alveolar air leak lasting beyond 5 days after pulmonary lobectomy is associated with worse postoperative outcomes.

Post-Intubation Tracheoesophageal Fistula: Surgical Management by Complete Cervical Tracheal Transection.

We report successful surgical management of post-intubation tracheoesophageal fistula (TEF) in an adult patient requiring long-term mechanical ventilation. A complete tracheal transection without tracheal resection, via an anterior cervical approach, followed by direct closure of tracheal and esophageal defect, and interposition of muscle flap between the suture lines and tracheal reconstruction was performed. In selected cases, this surgical procedure may be a viable alternative to traditional techniques used to treat post-intubation TEF via the anterior or lateral cervical approach.

Acquired Benign Tracheoesophageal Fistula: An Alternative Tracheoplastic Technique.

We present a case of surgical management of a tracheoesophageal fistula (TEF) following prolonged intubation. After transverse tracheal division and retraction of the distal stump, direct closure of the esophageal defect and repair of the membranous tracheal defect using a synthetic bioabsorbable patch were performed, followed by interposition of muscle flap between the suture lines and tracheal reconstruction. Large TEFs, without tracheal stenosis or circumferential airway defect, associated with marked peritracheal inflammation, may be treated with this alternative tracheoplastic technique in patients deemed not suitable for tracheal resection and anastomosis.

Unusual Periaortic Mediastinal Recurrence of Pulmonary Adenocarcinoma: When Making Diagnosis Is Really Necessary.

We report an unusual mediastinal recurrence along descending thoracic aorta during oncologic follow-up in a 47-year-old female smoker issued by lung adenocarcinoma with a history of left lower lobectomy and lingulectomy en bloc followed by adjuvant chemotherapy for stage III A-N2. Regional recurrence occurring along the staple line was suspected and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) combined to PET/CT allowed to reach definitive tissue diagnosis. High focal hypermetabolic activity on PET/CT at the site of suspect recurrence was necessary to check the lesion sampling by EBUS-TBNA.

Anomalous segmental pulmonary vein: additional V6 behind the bronchus intermedius draining into the superior pulmonary vein.

Anatomical variations of pulmonary venous drainage have been widely described in the literature in order to perform safe thoracic surgical procedures. We report a case of anomalous vein from the superior segment of the right lower lobe running in the posterior mediastinum and draining into the superior pulmonary vein. As the patient showed a usual right inferior pulmonary vein, formed by the union of the superior segment right lower lobe vein (V6) and the common basal vein joining the left atrium, the uncommon segmental pulmonary vein described was named: additional V6. It was identified preoperatively and recognized intraoperatively during thoracoscopic right lower lobectomy and lymph node dissection performed for lung cancer treatment. Diagnostic imaging and careful surgical dissection are helpful tools to avoid intraoperative bleeding and other complications during thoracic surgical procedures due to unrecognized vascular anomalies.

Different Therapeutic Strategies in 2 Young Patients with Advanced ALK-Rearranged Lung Adenocarcinoma: "The Light at the End of the Tunnel".

Malignant pleural effusion represents a prognostic negative factor on survival conferring stage IV disease. The median of survival is 5 months and a 5-year survival of about 3%. We describe the therapeutic success obtained from different strategies in anaplastic lymphoma kinase (ALK) inhibitors in 2 young women showing malignant pleural effusion secondary to advanced ALK-rearranged lung adenocarcinoma. This report shows that for patients with EGFR mutations in advanced lung adenocarcinoma-associated malignant pleural effusion, complete response to EGFR TKI inhibitor can be observed mostly if pleural effusion and primary lung adenocarcinoma show the same EGFR mutation status.

How to avoid "en masse" lobectomy using VATS technique in presence of hilar fibrosis.

Perivascular fibrosis is technically one of the most challenging issue to manage during thoracoscopic lobectomy and it is associated with increased risk of hemorrhagic injury. Here we report a case of thoracoscopic right lower lobectomy performed with individual dissection of segmental arteries due to dense adventitial fibrosis around the right lower lobe pulmonary artery. This approach may be considered as an alternative to the so-called "en masse" lobectomy and a way to avoid conversion to thoracotomy.

Emergency rigid bronchoscopy in two lower social class patients with mirror like complete pulmonary malignant atelectasis.

Several factors as cultural factors and social class other than biological and genetic factor can affect symptom perception in patients with malignant airway obstruction. Poor perception of dyspnoea can result in the delayed seeking of medical care so increase access to intensive care due to impeding respiratory failure. In patients issued from malignant airway obstruction, therapeutic bronchoscopy procedure can not affect the endotracheal extubation although immediate airway patency can be obtained. We reported the outcome of two patients from lower social classes admitted in intensive care and underwent emergency rigid bronchoscopy for malignant complete pulmonary atelectasis.

Variations in the branching patterns of pulmonary artery during thoracoscopic pulmonary resection.

PURPOSE: The knowledge of variations in the branching patterns of pulmonary artery may have important clinical implications in the field of thoracic surgery. METHODS: At the Department of Thoracic Surgery of Monaldi Hospital in Naples, between January 2017 and December 2019, 569 anatomic pulmonary resections via video-assisted thoracic surgery, including lobectomy and segmentectomy, were performed. RESULTS: Among the 569 thoracoscopic pulmonary resections, 24 variations in the branching patterns of pulmonary artery were identified and documented. Anatomic variations on the left were more frequent than on the right. CONCLUSION: This paper, providing a summary of vascular anomalies identified during major lung resections, could help surgeons avoid intraoperative complications, especially during minimally invasive procedures where the visual field is more restricted than open surgery.

Postoperative Bronchopleural Fistula: A Conservative Way of Treatment in Selected Cases.

BACKGROUND: Postoperative bronchopleural fistula represents a challenging issue for thoracic surgeons. The treatment options reported include bronchoscopic or surgical procedures but the method yielding the best results remains unclear. METHODS: In our thoracic surgery department, between January 2011 and June 2020, 11 patients treated conservatively for early bronchopleural fistula after lobectomy or bilobectomy were reviewed. The fistula size ranged between 2 and 3 mm and complete suture dehiscence. RESULTS: In all 11 patients favorable conditions such as clinical stability, complete expansion of the remaining lung, and resolution of the pleural infection allowed a successful conservative treatment with chest tube drainage. CONCLUSION: In selected cases, conservative management of early bronchopleural fistula after lobectomy or bilobectomy may be an alternative therapeutic option to bronchoscopic or surgical procedures, regardless of the fistula size.

Penetrating pulmonary injury caused by a steel rod.

In stable patients with penetrating thoracic trauma, a careful radiological assessment should be taken into account for a correct surgical management.

One lung ventilation management in a patient with Reinke's edema.

INTRODUCTION: Reinke's edema (RE) is a benign laryngeal disease. We describe the case of a patient with history of bilateral RE requiring surgical treatment, that came to our attention for a lung lobectomy due to adenocarcinoma. In consideration of the possible complications at the time of extubation and of the probable difficult control of the airways, the patient underwent intervention of microflap surgery for the RE at the same time of lobectomy. We opted for Bronchial Blocker (BB) using a Viva-sight™ Single Lumen Tube (SLT) Internal Diameter (ID) 7.0 mm (Ambu A/S, Baltorpbakken 13, DK-2750 Ballerup, Denmark) with integrated high-resolution camera. PRESENTATION OF CASE: The patient (female, 67 years old, BMI 28) was a candidate for lung lobectomy. She reported a RE requiring surgical treatment. An armoured Endo Tracheal Tube (ETT) ID 5.0 mm was positioned and microflap surgery was performed. Once this surgery ended, the armoured ETT was removed after placing an airway guide wire exchanger and a SLT ID 7.0 mm was placed. ​VivaSight-endoblocher™ (EB) was positioned in the right bronchus. DISCUSSION: We opted for double intervention, the risk that could result from the delay persuaded the patient to perform surgery for the RE. Postponing the lobectomy was dangerous for the oncological situation. The Viva-Sight SLT represented the right compromise. CONCLUSION: Even after the microflap, the space available for the ETT was reduced and, in order not to traumatize a tissue already stressed by surgery and to facilitate the tracheal intubation, we opted for BB using a Viva-sight™.

Left pulmonary artery pseudoaneurysm secondary to post-operative lung abscess.

A prompt diagnosis is mandatory to avoid fatal complications in case of pulmonary artery pseudoaneurysm.

Accessory V6 during thoracoscopic middle lobectomy: "an uncomfortable presence".

The identification of the accessory vein draining the superior segment of the right lower lobe (accessory V6), during the posterior mediastinal lymph node dissection, can help avoid operative complications.